Radial-capitellar implant

ABSTRACT

A radial-capitellar implant for surgical replacement of the capitellum of the humerus and, optionally, the head of the radius. The radial-capitellar implant includes a capitellar implant or surface replacement arthroplasty of the capitellum and a radial prosthesis for replacement of the head of the radius. In one embodiment the radial prosthesis includes an articular head which moveable articulates with a stem implantable in the radius.

STATEMENT OF RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.11/001,662, filed on Dec. 1, 2004 (allowed), which is herebyincorporated by reference in its entirety.

FIELD OF THE INVENTION

The invention relates generally to the field of joint replacementprostheses for the human body. More specifically, the invention relatesto joint replacement prostheses for the human elbow.

BACKGROUND OF THE INVENTION

The elbow is formed at the meeting of the distal end of the humerus andthe proximal ends of the radius and ulna. In the elbow, the head ofradius articulates with the capitellum of the humerus and radial notchof the ulna. The trochlear notch of the ulna articulates with thetrochlea of the humerus. When the forearm is in extreme flexion, thehead of the radius fits into the radial fossa located just above thecapitellum. The lateral epicondyle is found on the lateral aspect of thehumerus just above the capitellum. The lateral epicondyle serves as theinsertion for one portion of the supinator muscle which attaches atabout the proximal third of the radius.

Along their lengths the radius and ulna are joined by the interosseousligament, also known as the interosseous membrane. The interosseousligament has a fibrous structure that is oriented on a bias relative tothe axis of the forearm. This ligamentous interconnection between theradius and the ulna serves to transfer loads at the wrist from theradius to the ulna. At the wrist, the distal end of the radius is alarger and more robust structure than the head of the ulna. Thus, at thewrist a large share of the load carried by the hand is transferred tothe radius. However, at the elbow, the ulna is substantially larger thanthe head of the radius. The interosseous ligament serves to transferloads from the radius to the ulna so that the load is substantiallyequalized at the elbow or so the load is carried more by the ulna thanthe radius. The loading distribution between the radius and the ulna atthe humeral articulation is dynamic, varying with the position andmotion of the forearm and hand.

The radial head is an important component of normal elbow and forearmfunction. The radial head contributes to both the radiocapitellar andproximal radioulnar joints.

The radial head makes a 12 to 15 degree lateral angle to the radialshaft. This lateral angle is away from the radial tuberosity which islocated distal to the radial head on the medial side of the radius.Various ligaments about the radial head provide important soft tissuesupport and are essential to elbow stability. The stress distribution atthe elbow varies in pronation and supination but averages about 60percent to the radiohumeral joint and about 40 percent at the ulnarhumeral articulation.

The radial head can be damaged in many ways. One common source of damagethe head of the radius is a fall onto an outstretched hand.Historically, if the radial head was damaged so severely as to beimpossible to repair with the use of bone screws or other internalfixation structures, the radial head was resected and the elbow closed.Radial head resection was sometimes necessary due to fracture,osteochondrosis or secondary arthritis. Unfortunately, radial headresection tends to cause significant adverse effects on elbow andforearm function.

Resection of the radial head tends to cause persistent elbow instabilityfollowing elbow fracture, dislocation, rotational instability injuriesand medial lateral translation injuries. Excision of the radial head canalso cause forearm axial instability, particularly if the remainingstabilizing structures have been compromised. Since the radial head actsas a secondary stabilizer to the elbow joint, once the radial head isremoved the soft tissue stabilizers including the collateral ligaments,the interosseous membrane and the articular surfaces of the radial ulnarjoints may be compromised and the instability of the joint tends toincrease. Thus, replacement of the radial head with an implant has beenembraced as a way to attempt to restore anatomic normalcy and functionalusefulness to the elbow and forearm.

Radial head implants exist in the art. Typically, radial head implantsare available in multiple sizes to approximate anthropomorphicdifferences in radial head size in different patients. A radial headimplant generally will include a radial head component and a stemcomponent. The radial head component is designed to anatomicallyarticulate with the convexity of the capitellum for an anatomic jointsurface contact area. The circumference of the head matches the normalradioulnar joint articulation, preserves the annular ligament andminimizes release for exposure of important lateral ulnar collateralligament. The radial head and radial stem may be joined together by aMorse tapered protrusion that is adapted to interface with a Morsetapered cavity. Generally, the Morse tapered cavity is located in thehead which allows placement of the radial head onto the protrusion onthe radial stem.

A typical radial prosthesis has a stem configured for implantation intothe intramedullary canal of the proximal radius. Some types of radialhead implant include a limited ball joint articulation between theradial head component and the stem component. These are sometimes knownas bipolar implants. In this type of implant, the concave articularsurface of the radial head anatomically articulates with the convexityof the capitellum while the radial head articulates with the stem of theimplant. This allows the use of a radial head implant in situationswhere the radial head may be damaged in such a way as to makeimplantation of a fixed radial head implant difficult or impossible. Useof a bipolar radial head implant allows for some adjustment of the headof the implant with the capitellum once the implant is in place. Thearticulation between the head and the stem allows for the correction ofangular alignment deformities between the radius and the capitellum. Theball and socket design of this type of radial head implant allowsradial-capitellar contact to be maintained through a functional range offlexion and forearm rotation.

Unfortunately, some falls onto an outstretched hand will also damage thecapitellum of the humerus. In addition, the capitellum is sometimes tosubject to arthritic degeneration or increased wear after placement of aradial head implant.

As discussed above, sometimes resection of the radial head is performedwithout an implant. Resection of the radial head leaves the patient witha so-called ulna plus variation which tends to lead to wrist pain which,in turn, can be debilitating. For these reasons, it would be beneficialto the patient to be able to surgically replace and restore thecapitellum as well as the radial head.

Traumatic injury of the radioulnar joint is common. Injuries to theradioulnar joint include radial head fractures and radial head fracturesassociated with ligament injuries; combined proximal ulna fracture withradial dislocation or fracture; radial head fracture associated withdislocation of the elbow; and forearm and elbow injuries in combination.Forearm and elbow injuries include radial head fracture combined withinterosseous membrane disruption, the so-called Essex-Lopresti lesion.In the case of an Essex-Lopresti lesion or interosseous ligament tear,the transfer of loads from the hand and then from the radius to the ulnais compromised. This lack of transfer from the radius to the ulnacreates an increased load at the radial head where it meets thecapitellum which increases wear on the capitellum as well as the radialhead.

Thus, it would be beneficial to the orthopedic arts to have an implantavailable to surgically repair damage to the capitellum as well as tothe head of the radius.

SUMMARY OF THE INVENTION

The present invention solves many of the above mentioned problems bymaking available a radial-capitellar implant including a capitellarimplant to be implanted into the distal end of the humerus. Theinvention may also include a capitellar implant to replace thecapitellum of the humerus in combination with a radial head implant toreplace the head of the radius and to articulate with the capitellarimplant. Another aspect of the invention includes a capitellar implantand a bipolar radial head implant in which the head of the radial headimplant includes an articulated head that can conically, rotationally,articulate relative to the stem of the radial prosthesis to replace thehead of the radius.

The capitellar implant of the present invention generally includes abody and a stem. The body of the capitellar implant defines a convexarticular face. The convex articular face may have a spherical surfaceand extends about one hundred thirty five to one hundred forty degrees.The capitellar implant further includes a flat on its medial side and acurved flat on its lateral side. The curved flat on the lateral surfaceallows for excursion of the radial nerve over the lateral surface of theimplant. The curved flat also facilitates the smooth gliding of thejoint capsule and ligamentous structures over the implant duringflexion/extension and pronosupinatory motions. The convex articular faceallows articulation of the capitellar implant with the head of theradius over an arc of approximately one hundred thirty five to onehundred forty degrees to allow full range of motion in flexion andextension of the forearm.

The stem of the capitellar implant is offset approximately 10 degrees tothe medial side. The stem may be substantially square in cross sectionand tapered to a substantially square end. The stem of the capitellarimplant may be treated to encourage osseointegration such as byapplication of titanium plasma coating.

The side of the capitellar implant from which the stem extends includesa bone interface surface which may have two flat facets. The flat facetsare angled relative to one another at an angle of approximately 135degrees.

In another embodiment, the invention includes both the capitellarimplant as described above and a radial prosthesis for implantation toreplace the natural head of the radius where it articulates with thecapitellum and the ulna. In one embodiment of the invention, the radialhead implant includes a stem and a head.

The head of the radial head implant defines a concave articular surfacethat may be formed of ultra high molecular weight polyethylene (UHMWPE)or another durable self-lubricating material. The head further includesa stem interface portion which defines a substantially cylindricalcavity into which a portion of the stem inserts. The cavity may beformed with a morse tapered fit to allow ease of placement of the headonto the stem. The portion of the stem of the radial head implant thatis inserted into the intramedullary canal in this embodiment has asmooth continuous surface and a bend forming an angle which occurs aboutmidway down the length of the stem. The stem further includes a collarwhich abuts the head of the radial head implant along with the morsetapered extension to form the interface between the head and the stem.

In another embodiment, the radial head implant includes a head and astem that are joined by a ball and socket joint to allow for correctionof angular alignment deformities of up to about ten degrees. In thisembodiment, the radial head implant includes a head with a concavearticular surface that is lined with ultra high molecular weightpolyethylene or another durable self-lubricating material, anintermediate portion and a secondary articular portion which articulateswith the stem. The intermediate portion is typically formed of cobaltchromium stainless steel, titanium or another biocompatible metal. Thesecondary articular portion includes a female ball and socket interfaceand a male ball and socket interface to interface with the radialprosthesis stem.

Alternately, the articular portion and the intermediate portion can beformed as a single piece formed from UHMWPE or another durable selflubricating material. In this situation, the head of the radialprosthesis includes a female ball and socket interface and a male balland socket interface to interface with the radial prosthesis stem aswell as a concave articular face to articulate with the capitellarimplant.

The stem of this embodiment includes a stem with a collar similar tothat described above as well as a spheroidal ball protruding from thestem and extending from the collar in a direction opposite the stem. Thespheroidal protrusion rests in a spheroidal female cavity. The femalecavity accepts the male portion of the ball joint of the head portionand the spheroidal protrusion inserts into the female ball and socketportion of the head of the radial head implant. This structure increasesthe contact area between the articular head and the articular stemimproving the wear characteristics and distributing loading over alarger area. In this embodiment of the invention the stem may also betreated to encourage osseointegration such as by application of acommercially pure titanium plasma coating.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a plan view of the radial-capitellar implant in accordancewith the present invention in a flexed position;

FIG. 2 is a plan view of the radial-capitellar implant in a partiallyextended position;

FIG. 3 is a plan view of the radial-capitellar implant in a fullyextended position;

FIG. 4 is a perspective view of the radial-capitellar implant in aflexed position;

FIG. 5 is a perspective view of the radial-capitellar implant in apartially extended position;

FIG. 6 is a perspective view of the radial-capitellar implant in a fullyextended position.

FIG. 7 is an exploded perspective view of the radial-capitellar implant;

FIG. 8 is another exploded perspective view of the radial-capitellarimplant;

FIG. 9 is an exploded perspective view of another embodiment of theradial-capitellar implant;

FIG. 10 is an additional exploded perspective view of theradial-capitellar implant;

FIG. 11 is an elevational view of a capitellar implant in accordancewith the present invention;

FIG. 12 is a plan view of the capitellar implant;

FIG. 13 is a front elevational view of the capitellar implant;

FIG. 14 is a perspective view of the capitellar implant;

FIG. 15 is another perspective view of the capitellar implant;

FIG. 16 is another perspective view of the capitellar implant;

FIG. 17 is a plan view of the head of the radial implant;

FIG. 18 is a sectional view of the head of the radial implant;

FIG. 19 is a perspective view of the head of the radial implant;

FIG. 20 is a perspective view of the head of the radial implant;

FIG. 21 is a plan view of a stem interface component of the head of theradial implant;

FIG. 22 is a sectional view of the stem interface component of the headof the radial prosthesis with internal structures shown by phantomlines;

FIG. 23 is a perspective view of the stem interface portion of the headof the radial implant;

FIG. 24 is a perspective view of the stem interface portion of the headof the radial implant;

FIG. 25 is a plan view of the capitellar interface portion of the headof the radial implant;

FIG. 26 is a sectional view of the capitellar interface portion showinginternal structures in phantom.

FIG. 27 is a perspective view of the capitellar interface portion;

FIG. 28 is another perspective view of the capitellar interface portion;

FIG. 29 is a plan view of an alternate embodiment of the radialprosthesis head;

FIG. 30 is a sectional view with phantom lines showing internalstructures;

FIG. 31 is a perspective view of the radial component head;

FIG. 32 is another perspective view of the radial component head;

FIG. 33 is a plan view of a stem of an alternate embodiment of theradial head implant;

FIG. 34 is an elevational view of the stem showing internal structuresin phantom;

FIG. 35 is a perspective view of an alternate embodiment of the stem ofthe radial implant; and

FIG. 36 is another perspective view of an alternate embodiment of thestem of the radial implant;

DETAILED DESCRIPTION OF THE INVENTION

The radial-capitellar implant 40 of the present invention generallyincludes capitellar prosthesis 42 and radial prosthesis 44. Referringinitially to FIGS. 1-5 capitellar prosthesis 42 and radial prosthesis 44are shown in various views as articulated with one another in variousdegrees of flexion and extension.

Referring particularly to FIGS. 1-6 and 11-16 capitellar prosthesis 42generally includes body 46 and stem 48. Stem 48 is joined to body 46extending outwardly from bone interface surface 52 of body 46. Articularface 50 presents a substantially spheroidal surface. Body 46 and stem 48may be integrally formed from a single piece of material such as bycasting or machining.

Articular face 50 is smooth and may be mirror polished to facilitatesmooth articulation. Articular face 50 may present a substantiallyspheroidal convex surface Articular face 50 extends over an arc ofapproximately 170 to 190 degrees in a first direction and an arc of 80to 100 degrees in a second direction generally perpendicular to thefirst direction. In one embodiment, articular face 50 extends along anarc of about 170 to about one 190 in a first direction and along an arcof about 80 to about 100 degrees in a second direction, the seconddirection being substantially normal to the first direction. Articularface 50 further presents medial flat 54 and lateral curved flat 56.Lateral curved flat 56 presents straight portion 58 and curved portion60. Lateral curved flat 56 allows for excursion of the radial nerve overthe lateral aspect of articular face 50.

Bone interface surface 52 presents a first facet 62 and a second facet64. First facet 62 and second facet 64 meet at juncture 66 and form anobtuse angle 68 of approximately 130 to 150 degrees.

Stem 48 extends outwardly away from bone interface surface 52substantially at juncture 66.

Stem 48 may be substantially square in cross section and presentslateral side 70, medial side 72, superior side 74 and inferior side 76.These designations correspond to the positions of the sides whencapitellar prosthesis 42 is implanted in the humerus. Stem 48 extendsoutwardly from bone interface surface 52 and is angled medially relativeto bone interface surface 52. All corners 90 of stem 48 may be radiused.

Desirably medial side 72 of stem 48 displays bend 78. Thus medial side72 presents proximal surface 80 proximal to bend 78 and distal surface82 distal to bend 78. Proximal surface 80 forms an angle with firstfacet 62 of approximately ninety five degrees. A centerline of stem 48is angled approximately ten degrees from a perpendicular extendingoutwardly from first facet 62. Distal surface 82 of medial side 72 isangled approximately three degrees relative to the centerline of stem48. Lateral side 70 of stem 48 is angled approximately five degreesrelative to the centerline of stem 48. Stem 48 presents a substantiallyquadrilateral distal end 84. Superior side 74 of stem 48 is angledapproximately two degrees relative to a centerline of stem 48. Inferiorside 76 of stem 48 is angled approximately eight degrees relative tocenterline of stem 48. Stem 48 and bone interface surface 52 meet atfillet 86. Articular face 50 and bone interface surface 52 meet at edges87. Edges 87 are radiused around the perimeter 88 of articular face 50and bone interface surface 52 where articular face 50 and bone interfacesurface 52 meet.

Capitellar prosthesis 42 is formed of cobalt chrome alloy per ASTMF-1537 or another biocompatible, corrosion resistant material.Capitellar prosthesis 42 is desirably a unitary structure formed from asingle piece of material. Bone interface surface 52 and stem 48 may beroughened to encourage osseointegration such as by commercially puretitanium plasma coating.

Referring particularly to FIGS. 7 and 8, one embodiment of radialprosthesis 44 generally includes head 92 and stem 94. Referringparticularly to FIGS. 17-25, head 92 generally includes articularportion 96 and stem interface portion 98.

Referring particularly to FIGS. 25-28 articulation portion 96 of radialprosthesis 44 may be formed of UHMWPE or another durableself-lubricating material. Other polymers, composites or metals may alsobe suitable.

Referring particularly to FIGS. 26 and 27, articulation portion 96presents concave articular face 100 and engagement portion 102. Concavearticular face 100 may be spheroidal in curvature. Concave articularface 100 is surrounded by rim 104. Engagement portion 102 extendsoutwardly from articulation portion 98 on the opposite side from concavearticular face 100. Engagement portion 102 presents integral snap ring106 that extends radially outward defining indented circular groove 108.

Referring particularly to FIGS. 21-24, stem interface portion 98 may beformed from a rigid biocompatible material such as cobalt chrome alloy.Referring particularly to FIGS. 22 and 23, stem interface portion 98includes articular face cavity 110 which is dimensioned to acceptengagement portion 102 and snap ring 106 therein. Articular face cavity110 presents circular catch ring 112 surrounding the inner edge 114thereof. Circular catch ring 112 is dimensioned to fit into circulargroove 108 while snap ring 106 fits into the perimeter 116 of articularface cavity 110.

Referring particularly to FIGS. 22 and 24 stem interface portion 98further presents stem cavity 118. Stem cavity 118 is generallycylindrical in shape and may be formed with a morse taper. Steminterface portion 98 also presents concave portion 120 and convexportion 122. Stem interface portion may be formed of cobalt chrome alloysimilar to capitellar prosthesis 42 above. Stem interface portion may bemirror polished over its entire surface with particular attention beingpaid to concave portion 120 and convex portion 122 which may articulatewith soft tissues when implanted within the human body.

In another embodiment of the invention, head 92 may be formed having thesame shape and external structure as are articulation portion 96 andstem interface portion 98 together. In this embodiment, the entirety ofhead 92 may be formed from UHMWPE or another durable self-lubricatingmaterial or another polymer or composite.

Referring particularly to FIGS. 7 and 8, stem 94 generally includes boneinterface portion 124, collar 126 and extension 128. Bone interfaceportion 124 has a generally tapering shape with a rounded end 130. Boneinterface portion 124 may include a bend 132 occurring approximatelyhalfway between collar 126 and rounded end 130. Bone interface portion124 may also form a continuous curve. Collar 126 has a diameter largerthan both bone interface portion 124 and extension 128. Collar 126 maypresent an index notch 134 or other marking to indicate the direction ofbend 132. Extension 128 is substantially cylindrical in structure andmay be formed with a morse taper proportioned to fit into stem cavity118. Extension 128 and face 136 of collar 126 that make contact withstem interface portion 98 may be mirror polished. The remainder of stem48 including bone interface portion 124 and the remainder of collar 126may be roughened to encourage osseointegration such as by application ofa commercially pure titanium plasma coating. Stem 48 may take the formof the stem of the radial prosthesis disclosed in U.S. Pat. No.6,709,459, the contents of which are incorporated herein in theirentirety by reference.

Referring particularly to FIGS. 9, 10 and FIGS. 29-36, anotherembodiment of radial prosthesis 44 is depicted. In this embodiment,radial prosthesis 44 generally includes head 92 and stem 94. Head 92 andstem 94 may be articulated at ball joint 138.

Referring particularly to FIGS. 29-31, in this embodiment, articularhead 140 presents concave articular surface 142 surrounded by a radiusedrim 144. Articular head 140 further presents primary joint socket 146and secondary ball 148. Primary joint socket 146 is a substantiallyspheroidal cavity within articular head 140 including a narrowed portion150 and tapered portion 152. Secondary ball 148 includes spheroidalportion 154 and is surrounded by flat 156.

Referring particularly to FIGS. 33-36, in this embodiment stem 94 isarticular stem 158. Articular stem generally includes bone interfaceportion 160 which is substantially similar to bone interface portion 124of the prior discussed embodiment. Articular stem 158 further presentsgrooved collar 162 and head interface portion 164.

As seen in FIGS. 34 and 35, articular stem 158 presents primary jointball 166 and secondary socket 168. Primary joint ball 166 includesspheroidal portion 170 supported by base 172. Secondary socket 168defines a generally spheroidal cavity surrounding base 172 of primaryjoint ball 166. Articular stem 158 may be formed from cobalt chromesteel or another biocompatible material such as titanium.

Bone interface portion 160 of articular stem 158 may be roughened toencourage osseointegration such as by application of commercially puretitanium plasma coating. The portions of grooved collar 162 not expectedto contact bony tissues and the remainder of head interface portion 164may be mirror polished to facilitate smooth articulation with softtissues of the elbow.

In operation, capitellar prosthesis 42 is implanted to replace and/orresurface the capitellum of the humerus. To prepare a space to implantcapitellar prosthesis 42 a portion of the capitellum is resectedutilizing a resection guide (not shown) corresponding to the location ofthe first and second facets 62, 64 and a sagittal saw (not shown).Transverse and oblique cuts are made to the deep base of the capitellumand the resected portions are removed. After the capitellum is resecteda pilot hole is prepared in the capitellum and drilled into the distalhumerus. A broach is then used to enlarge the pilot hole and to shape itappropriately to create a cavity to receive stem 48 of capitellarprosthesis 42. Capitellar prosthesis 42 is intended for cementedimplantation. Prior to insertion of capitellar prosthesis 42, stem 48and bone interface surface 52 are coated with bone cement. If capitellarprosthesis 42 is being utilized for a hemi-arthroplasty of thecapitellum without replacement of the head of the radius, then theprocedure is complete and the site is closed.

If the radial-capitellar implant 40 is utilized for a completearthroplasty including replacement of the capitellum with capitellarprosthesis 42 and replacement of the head of the radius with radialprosthesis 44, the following procedure is also performed. Resection ofthe radial head is performed by making a cut at the radial neckutilizing a resection guide (not shown.) During resection the forearm ispronated and supinated while the cutting guide is used to align the sawblade perpendicular to the axes of rotation of the radius.

The intramedullary canal of the radius is entered using a starter awl ina twisting motion. The intramedullary canal is then broached to theappropriate size and shape to receive stem 94 of radial prosthesis 44.With capitellar prosthesis 42 in place, stem 94 of radial prosthesis 44is inserted into the broached cavity in the radius and radial prosthesis44 is assembled by installing head 92 on stem 94. Following assembly ofradial prosthesis 44, capitellar prosthesis 42 is articulated with head92 of radial prosthesis 44. Articular face 50 of capitellar prosthesis42 articulates with concave articular face 100 of radial prosthesis 44.

If the embodiment of radial prosthesis 44 is utilized that includesarticular head 140 connected to articular stem 158 by ball joint 138,articular head 140 also articulates with articular stem 158 about balljoint 138. It is notable that the load born by ball joint 138 istransferred largely at the interface between secondary ball 148 andsecondary socket 168 while primary joint ball 166 articulates withprimary joint socket 146 and bears a lesser portion of the load. Concavearticular face 100 articulates with articular face 50 in both a slidingand a rotational fashion. In addition, ball joint 138 allows conicalrotation of articular head 140 relative to articular stem 158 thusadjusting for possible misalignment between articular head 140 andcapitellar implant 142.

The above summarizes the technique of implantation of the invention,however a more detailed surgical procedure can be found below.

Surgical Technique

Initial Incision

Place the patient under a general or a regional anesthesia. Make aclassic Kocher skin incision identifying the interval between theanconeus muscle and the extensor carpi ulnaris. The incision shouldextend approximately 6-7 cm. Carry dissection down to the joint capsule.The origin of the anconeus can be released subperiosteally and retractedposteriorly to permit adequate exposure of the capsule.

Capsular Exposure

If the elbow is stable, expose the capsule by elevating a portion of theextensor carpi ulnaris sufficiently to allow identification of thelateral collateral ligament complex. Alternatively, split the extensorcarpi ulnaris longitudinally in line with its fibers staying anterior tothe attachment of the lateral collateral ligament. Divide the lateralcapsule slightly anteriorly to the collateral ligament and the annularligament and reflect the capsule anteriorly and posteriorly to exposethe radial head. A portion of the lateral collateral ligament andanterior capsule can be reflected off the lateral epicondyle andanterior humerus to expose the capitellum. The lateral ulno-humeralligament should not be disturbed. If the ligament has been disrupted,then proceed through the site of disruption to expose the radiohumeraljoint. Retract the common extensor tendon and elbow joint capsule asneeded to maximize exposure.

Capitellar Resection Guide

Place the capitellar resection guide (not shown) over the capitellum.Perform transverse and oblique cuts to the deep base of the capitellum.Using a rongeur, remove the capitellar head and trim remainingfragments, as needed.

Capitellar Trial and Drill Guide

Place a capitellar trial (not shown) against the resected humerus.Insert K-wires through holes in the trial and into the distal humerus tofirmly seat the trial component. Using an appropriately sized drill,drill a broach pilot hole into the distal humerus. If using thecapitellar implant alone as a hemi-arthroplasty of the capitellum,radial head resection is not necessary, therefore proceed to the step ofIntramedullary Preparation, Distal Humerus below.

Radial Head Resection Guide

Resect the radial neck utilizing a resection guide (not shown.)Resection of the radius utilizing a resection guide is disclosed in U.S.Pat. No. 6,709,459.

During the resection, the forearm is pronated and supinated while thecutting guide is used to align the sawblade perpendicular to the axis ofrotation defined by the resection guide. The extent of resection of theradius should be minimized. For example, the distal extent of resectionmay be the minimal amount that is consistent with the restoration offunction as dictated by a fracture line in the radius or a previousradial head resection. In addition, radial length should be restoredusing a lamina spreader to apply axial traction if there is a positiveulna variance.

Intramedullary Preparation, Proximal Radius

If the elbow is unstable, varus stress and rotation of the forearm intosupination allows improved access to the medullary canal. If the elbowis stable but the exposure is not adequate to access the medullarycanal, careful reflection of the origin of the collateral ligament fromthe lateral epicondyle may be necessary to permit subluxation to accessthe medullary canal. Enter the canal with a starter awl using a twistingmotion. Broach the canal taking care to identify the proper axialorientation. The forearm should be in mid-rotation with the tuberositydirected medially. This position is favorable for broaching andimplantation as the curve of the broach/implant points lateral or awayfrom the radial tuberosity. Serial sized broaches are used until thebroach fits snugly in the canal to an appropriate depth.

Trial Reduction, Proximal Radius

A trial stem is inserted into the broached cavity and a trial radialhead is placed on the trial stem. Assure that the stem's collar is flushwith the resected head of the radius. Tracking, both in flexion andextension and forearm rotation should be carefully assessed.Misalignment of the radial osteotomy will cause abnormal tracking duringflexion-extension and/or forearm pronation and supination. Remove theradial head and stem trials if tracking and alignment is satisfactory.

Intramedullary Preparation, Distal Humerus

Remove the capitellar trial and K-wires to allow access to the broachpilot hole. Insert broach into the pilot hole and impact. Care should betaken to maintain proper alignment with the drilled pilot hole. Continuebroaching the distal humerus until the broach fits snugly in the canalto an appropriate depth.

Implanting the Final Components

Once acceptable alignment has been determined, a permanent prosthesiscan be inserted. Distraction of the proximal radius may be necessary toallow sufficient access for capitellar prosthesis 42 insertion. Insertthe stem 48 into the canal and tap into place using an impactor (notshown). Polymethyl methacrylate (PMMA) bone cement is recommended forthe capitellar component. If using the capitellar prosthesis 42 as ahemi-arthroplasty of the capitellum, proceed to the step of Closurebelow.

Insert the radial stem 94 of radial prosthesis 44 into theintramedullary canal of the proximal radius and tap it into place withan impactor. Bone cement is recommended unless a secure fixation ispresent at the time of the insertion of the trial stem (i.e. stem cannotbe easily extracted from the medullary canal). Next, place head 92 overextension 128 using longitudinal distraction and/or varus stress todistract the radio capitellar interface sufficiently to permit head 92to be placed on extension 128. Once inserted, secure head 92 using animpactor or an assembly tool. Reduce the elbow and again test the rangeof motion in flexion/extension and pronation/supination.

Closure

Close the incision. The forearm is placed in full or partial rotationbefore sutures are tied. The elbow is splinted at 90 degrees flexion andin neutral to full pronation.

Aftercare

Passive flexion and extension is permitted on the second day assumingthe elbow is considered stable. The goal of radial head replacement andsoft tissue repair is to achieve elbow stability.

Both flexion/extension and pronation/supination arcs are allowed withoutrestriction. Active motion can begin by day five. Long term aftercarerequires monitoring as with any prosthetic replacement.

The present invention may be embodied in other specific forms withoutdeparting from the central attributes thereof, therefore, theillustrated embodiment should be considered in all respects asillustrative and not restrictive, reference being made to the appendedclaims rather than the foregoing description to indicate the scope ofthe invention.

What is claimed is:
 1. An implantable joint prosthesis for implantationat the radiocapitellar joint, the joint prosthesis comprising: acapitellar prosthesis configured to replace a capitellum while leavingan adjacent trochlea substantially intact, the capitellar prosthesiscomprising: a body having a smooth convex articular surface having alateral flat adapted to allow for excursion of the radial nerve over thearticular surface, and a bone interface surface on a side of the bodyopposite to the convex articular surface, the bone interface surfacehaving a first facet and a second facet positioned inferior to the firstfacet, the first facet being oriented relative to the second facet at anobtuse angle on the side of the body opposite the convex articularsurface; and a first stem extending outwardly away from the boneinterface surface, the stem including a lateral side, a medial side, asuperior side and an inferior side, the medial side having a bend alonga portion of the medial side and the lateral side is angledapproximately 5 degrees relative to a centerline of the stem.
 2. Thejoint prosthesis as claimed in claim 1, wherein the convex articularsurface is substantially a partial spheroid.
 3. The joint prosthesis asclaimed in claim 1, wherein the convex articular surface extends alongan arc of about one hundred seventy to about one hundred ninety degreesin a first direction and along an arc of about eighty to about onehundred degrees in a second direction, the second direction beingsubstantially normal to the first direction.
 4. The joint prosthesis asclaimed in claim 1, wherein the first stem is treated to promoteosseointegration.
 5. The joint prosthesis as claimed in claim 1, whereinthe first stem has a substantially quadrilateral cross section.
 6. Thejoint prosthesis as claimed in claim 1, wherein the first stem issubstantially tapered along its length.
 7. The joint prosthesis asclaimed in claim 1, wherein the first stem extends outwardly from thebone interface surface at a junction between the first facet and thesecond facet.
 8. The joint prosthesis as claimed in claim 1 furthercomprising: a radial head prosthesis, the radial head prosthesiscomprising a second stem and a head, the head having a concave articularsurface.
 9. The joint prosthesis as claimed in claim 8, wherein theconcave articular surface is formed of UHMWPE.
 10. The joint prosthesisas claimed in claim 8, wherein the concave articular surface is formedof a polymeric substance.
 11. The joint prosthesis as claimed in claim8, wherein the convex articular surface of the capitellar prosthesis issubstantially a partial spheroid.
 12. The joint prosthesis as claimed inclaim 8, wherein the convex articular surface of the capitellarprosthesis has a lateral flat adapted to allow for excursion of theradial nerve over the articular surface.
 13. The joint prosthesis asclaimed in claim 8, wherein the convex articular surface extends alongan arc of about one hundred seventy to about one hundred ninety degreesin a first direction and along an arc of about eighty to about onehundred degrees in a second direction, the second direction beingsubstantially normal to the first direction.
 14. The joint prosthesis asclaimed in claim 8, wherein at least a portion of the capitellarprosthesis is treated to promote osseointegration.
 15. The jointprosthesis as claimed in claim 8, wherein the first stem has asubstantially quadrilateral cross section.
 16. The joint prosthesis asclaimed in claim 8, wherein the first stem is substantially taperedalong its length.
 17. The joint prosthesis as claimed in claim 8,wherein the first stem extends outwardly from the bone interface surfaceat a junction between the first facet and the second facet.
 18. Thejoint prosthesis as claimed in claim 1 further comprising: a radial headprosthesis, the radial head prosthesis comprising a second stem and ahead, the head having a concave articular surface, the head being formedentirely from UHMWPE.
 19. The joint prosthesis as claimed in claim 1further comprising: a radial prosthesis, the radial prosthesiscomprising a second stem and a head, the head being articulated to thesecond stem by a ball joint.
 20. The joint prosthesis as claimed inclaim 19, wherein the ball joint comprises a primary ball articulableinto a primary joint socket and a secondary ball articulable into asecondary joint socket.
 21. The joint prosthesis as claimed in claim 20,wherein the primary ball is supported by the second stem, the primarysocket is defined by the head, the secondary ball is supported by thehead and the secondary socket is defined by the second stem.
 22. Thejoint prosthesis as claimed in claim 20, wherein the primary ball, theprimary socket, the secondary ball and the secondary socket share asubstantially commonly located center.
 23. The joint prosthesis asclaimed in claim 1, wherein the first stem further comprises at leastone of the lateral side, inferior side and superior side as planar fromproximate an end of the first stem to proximate the bone interface. 24.The joint prosthesis as claimed in claim 23, wherein a portion of themedial side proximal to the bend is angled approximately 95 degreesrelative to the first facet.
 25. The joint prosthesis as claimed inclaim 23, wherein a portion of the medial side distal to the bend isangled approximately 3 degrees relative to a centerline of the stem. 26.The joint prosthesis as claimed in claim 23, wherein each of the lateralside, inferior side and superior side is planar.
 27. The implantablejoint prosthesis of claim 26, wherein a cross-section of the end of thefirst stem is substantially quadrilateral.
 28. The joint prosthesis asclaimed in claim 1, wherein the convex articular surface of thecapitellar prosthesis includes a first lateral surface and a secondlateral surface.
 29. The joint prosthesis as claimed in claim 28,wherein the first lateral surface is planar and the second lateralsurface includes a planer portion and a curved portion.
 30. The jointprosthesis as claimed in claim 1, wherein the bend is on a medial sideof the first stem relative to the radiocapitellar joint when the jointprosthesis is implanted.
 31. The joint prosthesis as claimed in claim 1,wherein the bend is formed between a proximal surface and a distalsurface, the proximal surface forming an angle with the first facet ofapproximately 95 degrees.